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  8. Supporting patients at risk of malnutrition

Supporting patients at risk of malnutrition

There are different treatment options to manage malnutrition. Commonly, first-line dietary advice is provided with some patients also requiring short-term use (usually 12-weeks) of oral nutritional provided by health and social care professionals.

First-line dietary advice

What initial actions can a non-dietitian (nurses, GPs, or any other allied health professional) advise?

This section is focused on providing basic steps to prevent and/or tackle malnutrition as well as to address the most troublesome nutrition-related symptoms.

Aim for the 'Food first' principle, which means addressing all nutritional needs through the use of food rather than supplements (Barazzoni et al., 2020; Malnutrition Pathway, 2020 [PDF]).

Step 1
  • Assess the patient using nutritional assessment (refer to local guidance for the assessment of malnutrition if available) and consider the causes for any nutritional issues
Step 2
  • Encourage the patient with food first approaches – please see the 'Food first' principle for eating more or eating differently above
  • In particular, encourage fortified drinks (see recipes in the diet fortification section) before considering ONS, because home-made food and drinks are cheaper and can be adapted to the patient's taste preferences more easily
  • Establish appropriate goals with the patient. For example, if weight change is one problem (either loss or gain), preventing further change may be the best goal in the first instance
  • Follow your local guidance for dietetic referral as required
  • Only consider ONS if the patient is at risk of malnutrition and is unable to meet their nutritional requirements through food and nutritious fluids alone. Refer to local criteria and guidance for ONS options. In the absence of local guidance the British National Formulary (BNF) provides a list of nutritional supplement composition and brand
Step 3
  • Once therapy with ONS has been started, it is crucial to review progress to avoid unintended complications such as excess weight gain. Nutritional status and nutritional goals should be monitored at regular intervals. Find out more in our Monitoring patients during their COVID-19 recovery section
Step 4
  • If there is no improvement in the patient’s nutritional status, seek advice from a registered dietitian

Use of Oral Nutritional Supplements (ONS)

Refer to your local guidance for ONS (this should be available through your prescribing support dietitians or medicines management team – your pharmacist may be able to support to find the right guidance).

Other points to consider:

  • There may be long term issues with the diet that could have been neglected, and now is an opportunity to improve them
  • Consistent information is important to patients. Consider patients' communication needs and food culture e.g. reading level, braille, relevance to their culture etc
  • Offer suggestions for meals and snacks (Cawood et al., 2020) (see links provided above).

Enteral or parenteral nutrition

Indications

Unless there is dysphagia or neurological dysfunction (Cawood et al., 2020) or when nutritional needs cannot be met orally or through enteral nutrition for more than three days (Barazzoni et al., 2020). Consider logistics at home. Safety and practice are not included in this hub but you can consult with your rehabilitation team (Cawood et al., 2020).

Further advice is available here.

Guidelines

Cawood et al. have reviewed nutrition support guidelines and this paper summarises key themes of those publications linked to nutrition support of adults with or recovering from COVID-19 outside of hospital. The three themes across all guidelines include:

  1. screening for malnutrition, which can be achieved by remote consultation
  2. care plans with appropriate nutrition support, which may include food-based strategies, oral nutritional supplements and referral to a dietitian
  3. continuity of nutritional care between settings including rapid communication at discharge of malnutrition risk and requirements for ongoing nutrition support


This reflects the information provided in this Knowledge Hub.

National Institute for Health and Care Excellence (NICE)